Provider Demographics
NPI:1245276005
Name:STOUT, JULIANNE (MD)
Entity type:Individual
Prefix:DR
First Name:JULIANNE
Middle Name:
Last Name:STOUT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 N 400 W
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-4620
Mailing Address - Country:US
Mailing Address - Phone:615-542-9664
Mailing Address - Fax:
Practice Address - Street 1:148 SAGAMORE PKWY W
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1569
Practice Address - Country:US
Practice Address - Phone:765-314-3515
Practice Address - Fax:833-874-0936
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01068694A207R00000X
TN29127207R00000X
TN01068694A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
G88911Medicare UPIN
TN3836865Medicare ID - Type Unspecified